Why Some Opioids Users Don’t Fear a Fatal Overdose

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"A couple years ago, when local news agencies reported a spike in overdose deaths related to fentanyl in St. Paul, Minnesota, clinicians at an outpatient treatment clinic in that city saw an immediate effect. "A dozen of our patients disappeared," says Dr. Marvin Seppala, chief medical officer of the Minnesota-based Hazelden Betty Ford Foundation. "They'd been in treatment from six weeks to two years and were sober." The patients dropped out of the program to try fentanyl, a synthetic opiate painkiller that was new to the area. "Nobody in their right mind would want to get near fentanyl, which is 50 to 100 times more powerful than morphine and up to 50 times stronger than heroin," he says. "Our patients heard about fentanyl and thought, 'I want to try that.' They wanted to recapture the euphoric high they hadn't felt since they'd started using." Luckily, Seppala says, none of these patients died during their relapses. Still, the anecdote helps explain why the deadly opioid epidemic is getting worse; the grim fact is that some people with opioid use disorder are drawn to substances they know might kill them – and not because they're suicidal. The pull helps explain the growing death toll the opioid crisis is exacting. Every day, more than 115 people in the United States die of an opioid overdose, according to the National Institute on Drug Abuse. More than 64,000 people died of drug overdose in the U.S. in 2016, and the lion's share of those fatalities – more than 42,000 – involved opioids, a record number, according to the Centers for Disease Control and Prevention. Opioid overdoses in recent years have claimed the lives of acclaimed actor Philip Seymour Hoffman and the musicians Prince and Tom Petty. Opioids include heroin and prescription medications such as hyrdrocodone, oxycodone, oxymorphone, morphine, codeine and fentanyl. Lately, authorities have seen carfentanil – which is typically used to tranquilize elephants and other large animals – show up on the street. Carfentanil is about 100 times more potent than fentanyl and 10,000 times stronger than morphine, according to the Drug Enforcement Administration. Luckily, Seppala says, none of these patients died during their relapses. Still, the anecdote helps explain why the deadly opioid epidemic is getting worse; the grim fact is that some people with opioid use disorder are drawn to substances they know might kill them – and not because they're suicidal. The pull helps explain the growing death toll the opioid crisis is exacting. Every day, more than 115 people in the United States die of an opioid overdose, according to the National Institute on Drug Abuse. More than 64,000 people died of drug overdose in the U.S. in 2016, and the lion's share of those fatalities – more than 42,000 – involved opioids, a record number, according to the Centers for Disease Control and Prevention. Opioid overdoses in recent years have claimed the lives of acclaimed actor Philip Seymour Hoffman and the musicians Prince and Tom Petty. Opioids include heroin and prescription medications such as hyrdrocodone, oxycodone, oxymorphone, morphine, codeine and fentanyl. Lately, authorities have seen carfentanil – which is typically used to tranquilize elephants and other large animals – show up on the street. Carfentanil is about 100 times more potent than fentanyl and 10,000 times stronger than morphine, according to the Drug Enforcement Administration.  The grim fact is that for many people with opioid use disorder, the lethality of a particular batch of drugs isn't a deterrent – it's an attraction, says Howard Samuels, chief executive officer of The Hills Treatment Center in Los Angeles. Samuels, 60, speaks from experience: He's been in recovery from heroin addiction for more than 30 years. "When I was on the streets of New York, when we heard a brand of heroin was causing people to overdose and killing them, we wanted that brand of heroin so badly," Samuels says. "We thought the people who were dying didn't know how to shoot it [properly]. I thought [overdosing] won't happen to me." This mindset is illogical, but it makes sense to someone struggling with substance use disorder, because denial is a hallmark of addiction, Samuels says. "It's all about denial and rationalization," he says. "I was shooting heroin and thought I was still in control. It was absolutely crazy." The introduction of fentanyl and carfentanil as readily available street drugs has made using opioids much riskier than it was in the past. Fentanyl and carfentanil are sometimes sold on the street or are laced in other drugs, like heroin. Some opioid users know they're buying drugs that contain fentanyl or carfentanil, and some don't. The lure of a high from either of those substances would have been too great for him to resist during his active addiction, Samuels says. "If I was shooting heroin today, I'd be dead, no question," he says. This risk separates opioids from alcohol and other drugs that are misused, says Dr. Joseph Garbely, medical director at Caron Treatment Centers, which has facilities in Pennsylvania and Florida. For people who are in early recovery, for example, relapse is common – and when it comes to opioids, it can be deadly, Garbely says. Between 40 and 60 percent of people who've been treated for substance use disorder, whether it's for drugs or alcohol, relapse within a year, according to a 2014 study in the Journal of the American Medical Association. "If someone [who's in early recovery] goes into a bar and grabs a drink, he or she won't necessarily end up dead or in extreme circumstances," Garbely says. "For an opioid user, a relapse could be an immediate course of death." In response to the opioid epidemic, health officials and parents are using a variety of strategies to try to keep people with opioid use disorder alive. For example, some parents have resorted to calling law enforcement authorities on their kids to have them arrested in the hope of preventing them from overdosing. Throughout the country, health officials are teaching traditional first responders, such as police, and nontraditional ones, like civilians, how to use naloxone to rescue people who have overdosed on opioids. Naloxone is a medication that blocks the effects of opioids and can reverse an overdose.  People with opioid use disorder who are seeking to replicate their initial euphoric high aren't the only ones at risk of overdosing, says Dr. Carla Marienfeld, an associate clinical professor in the psychiatry department at the University of California, San Diego. Some people put themselves at risk by ingesting opioids simply to avoid feeling terrible. For example, if someone's used opioids for a year or more, his or her body has become accustomed to having the drug in its system. "Once your body is accustomed to high levels of opioids, it's like a new set point," Marienfeld says. "Some people who've been using opioids for a while need the drug in order to just feel normal." Most people who misuse opioids evolve from getting high to over time needing to use them to feel normal to ingesting their drug of choice to avoid terrible withdrawal symptoms when they're trying to quit using, Marienfeld says. These symptoms can include nausea, vomiting or diarrhea; muscle pain; a rapid heart rate; tremors; fever and sweating; insomnia and agitation. The severity and duration depends on several variables, such as how long the individual has been using opioids and the level of his or her dependence. Typically, people who have been using drugs for longer periods of time will have more difficult withdrawal symptoms. For short-acting opioids, such as fentanyl and heroin, the main physical withdrawal occurs quickly, is very intense and typically passes within a day or two, Marienfeld says. Peak physical withdrawal symptoms typically last about a week, says Dr. Sidarth Wakhlu, an addiction psychiatrist with UT Southwestern's Peter O'Donnell Jr. Brain Institute in Dallas.  "My patients say, 'I use enough drugs so I can feel normal,'" Wakhlu says. "Without drugs they're miserable, they have no energy, they want to stay in bed all day and have intense cravings. [Using is] not about achieving a euphoria or getting high as they progress in their addiction." The desire to avoid withdrawal continues the cycle of drug use, which patients know might lead to a potentially fatal overdose. "It doesn't mean they're suicidal or uninformed," Wakhlu says. "It's the nature of addiction. Addiction is powerful, cunning and baffling."' -Written by Ruben Castaneda for U.S. News at: https://health.usnews.com/wellness/articles/2018-04-23/why-some-opioids-users-dont-fear-a-fatal-overdose